Not so long ago, there was a big push to reduce the amount of paper generated in health care. A major effort was also underway to computerize all medical records to improve access from the many specialists/providers that have become involved in taking care of a patient. Millions were spent but no standards were ever set forth to make sure that the many vendors involved would develop records that could not only communicate with payers but which would be able to interact with other versions. Sadly, that effort ended up creating almost as many problems as it solved. The “computerized” record required fitting information into vendor specific formats and ate much of the time a provider could have used treating a patient.

Meantime, the paperwork actually increased largely because of the HIPAA act which created more documentation designed to “protect” privacy and establish a record that showed that the privacy had been protected complete with a signed copy by the patient or guarantor that they had been advised and received a COPY. Often those entry forms grew from 1 or 2 to 15 or more actual pieces of paper.

Medical billing, always relatively complicated, had lots of new rules related to new codes, proof with documentation for the diagnosis and treatment, and the growing concern about the quality of medical care, its outcome, and how to create the data to track and mine it for various purposes.

On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) proposed historic changes that would increase the amount of time that doctors and other clinicians can spend with their patients by reducing the burden of paperwork that clinicians face when billing Medicare. They set up listening sessions all over the country and heard from thousands of providers. One thing they consistently brought up was how documentation was needlessly burdensome, wasn’t improving patient care, and was actually having a negative impact on patient care. CMS listened and in response proposed streamlining the documentation requirements for the tricky Evaluation and Management (E&M) codes and descriptors, as well as moving to single payment rates.


CMS Video